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N932 Pathophysiology > Obstructive Lung Disease > Flashcards

Obstructive Lung Disease Flashcards

1
Q

driving pressure

A

=Pplat-PEEP and represents the ratio between TV and compliance

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2
Q

obstructive lung diseases characteristic

A

largely normal TLC
decreased FEV ratios
characterized by airflow limitation

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3
Q

OSA definition

A

mechanical obstruction of breathing that occurs during sleep when pharyngeal muscles relax

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4
Q

OSA precipitating factors

A

obesity is biggest one, and usually males

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5
Q

OSA clinical features

A

hypoxemia, hypercarbia, low FRC, comorbidities related to obesity and hypoxemia
hallmark: snoring, fragmented sleep, daytime somnolence

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6
Q

OSA comorbidities precipitated by obesity and hypoxemia

A

systemic and pulmonary hypertension
ischemic heart disease
CHF

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7
Q

OSA dx

A

polysomnography, berlin test, STOPBANG

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8
Q

polysomnography

A

records number of abnormal respiratory events.

includes apnea plus hypo apnea index, AHI

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9
Q

AHI score

A

> 5 associated with sleep related symptoms
15 is diagnosis for moderate OSA
30 severe OSA

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10
Q

STOPBANG pneumonic

A 
Snores loudly
daytime tiredness
observed stop breathing
high pressure
BMI >35kg/m^2
age >50y
neck circumference >40cm
gender: male
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11
Q

what does an obstructive flow volume curve look like

A

normal inspiration, scooping during exhalation. indicative of asthma, COPD, air trapping

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12
Q

what does a flow volume curve look like for a fixed obstruction

A

even and smaller inhalation and exhalation curves. can’t breathe in deep, can’t breathe out fast. example is tracheal stenosis

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13
Q

what does a flow volume curve look like for an extra thoracic lesion

A

exhalation largely normal, inhalation almost nonexistent. lesion outside chest wall is making it hard to breathe. when you exhale, you “blow out the narrowing”

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14
Q

what does a flow volume curve look like for an intra thoracic lesion

A

inspiration largely normal, exhalation largely abnormal/lessened.

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15
Q

what does spirometry include (6)

A

FEV1, FVC, FEV1/FVC ratio, FEV25-75%, MVV, DLCO

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16
Q

FEV1

A

forced expiratory volume measured in 1 second. the volume of air forcefully exhaled in once second (normal is 80-120% of TLC. 80% would be ~4L)

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17
Q

FVC

A

forced vital capacity. the volume of air forcefully exhaled after a deep inhalation. (3.7L in females, 4.8L in males)

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18
Q

FEV1/FVC ratio

A

normal is 75-80%. amount you can blow out in 1 second versus how much you blow out completely.

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19
Q

FEV 25-75%

A

measurement of air flow at midpoint of a forced exhalation. tells you about exhalation sustainability

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20
Q

maximum voluntary ventilation (MVV)

A

maximum amount of air that can be inhaled and exhaled in one minute (or 15s).
males are usually 140-180
females usually 80-120L/min

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21
Q

DLCO

A

diffusing capacity. volume of carbon monoxide (CO) and helium transferred across the alveoli into the blood per minute per unit of alveolar partial pressure. a single breath of .3% CO and 10% helium is held for 20 seconds. normal value is 17-25mL/min/mmHg

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22
Q

s/sx of URI, general

A

non productive cough, sneezing, rinorrhea

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23
Q

s/sx of URI, bacterial

A

more serious. includes fever, purulent nasal discharge, productive cough, malaise. patients may present tachypneic and wheezy. active fever, may cancel.

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24
Q

risk factors for pediatric patient complications include

A

actively sick
history of reactive airway disease
ETT intubation
airway surgery

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25
Q

if you cancel a surgery r/t a URI, how long will it be postponed?

A

at least 6 weeks

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26
Q

anesthetic management of URI patients include

A

hydration
reduction of secretions
limiting airway manipulation (induce when completely relaxed/deep)
LMA v ETT. while LMA is “no airway manipulation”, you have higher aspiration risk

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27
Q

adverse respiratory events related to URI patients include

A

bronchospasm (run them deep), laryngospasm (CPAP usually breaks it), airway obstruction, postoperative croup (usually self limiting), desaturation

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28
Q

asthma definition and characteristics

A

reversible airway obstruction. episodic.
(inflammation, edema, airway narrowing, decreased ability to exhale)
characterized by bronchial hyperreactivity, bronchoconstriction, chronic inflammation of lower airways

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29
Q

asthma pathophysiology

A

activation of inflammatory pathway leads to infiltration of airway mucous with eosinophils, neutrophils, mast cells, T cells, B cells. inflammatory mediators include histamine, prostaglandin D, leukotrienes.
airway edema results, thickening of basement membrane. simultaneous edema and repair
higher risk for anesthesia complications

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30
Q

how long does asthma episode last

A

minutes to hours

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31
Q

asthma clinical manifestations

A

wheezing, productive and nonproductive cough, dyspnea/SOB, chest discomfort leading to air hunger, eosinophilia

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32
Q

status asthmaticus

A

episode of asthma/”bronchospasm” that persists despite tx

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33
Q

asthma and dx

A

usually based on s/sx
-obstruction is partially reversible with bronchodilators
PFT’s including FEV1 <35% normal
downward scooping of expiratory limb of flow volume curve
increase in FRC but TLC remains WNL
DLCO unchanged, not a diffusion issue

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34
Q

do ABG’s tell you much about an asthma exacerbation

A

based on level of disease
normal ABG in mild disease
hypocarbia and respiratory alkalosis can be commonly seen, reflects neural reflex changes in lungs, not hypoxemia
severe obstruction r/t PaO2 <60mmHg, rises in PaCO2 noted when FEV1 less than 25%. fatigue in accessory muscles contributes to hypercarbia

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35
Q

what does a severe* asthmatic look like on CXR

A

hyperinflation, hilar congestion due to mucous plugging and pulmonary hypertension

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36
Q

what may an EKG look like on an asthma patient

A

RV strain associated with increased pulmonary pressures may be evident. this would be T wave inversion in R precordial leads (V1-4) and inferior leads (II, III, aVF)

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37
Q

treatment of asthma

A 
emphasis of treatment is on inflammation and bronchospasm. 
includes corticosteroids 
long acting bronchodilators
leukotriene modifiers
anti IgE monoclonal antibody
methylxanthines
mast cell stabilizer
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38
Q

corticosteroid used with asthma patient treatment

A

beclamethasone

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39
Q

long acting bronchodilators used with asthma patient treatment

A

salmeterol or

combo of symbicort and advair

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40
Q

leukotriene modifier used with asthma patient treatment

A

singulair

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41
Q

anti IgE monoclonal antibody used with asthma patient treatment

A

omalizumab

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42
Q

methylxanthines used with asthma patient treatment

A

theophylline (PDE inhibitor, can be toxic)

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43
Q

mast cell stabilizer used with asthma patient treatment

A

cromolyn

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44
Q

what FEV1 % indicates that an asthmatic would be symptom free

A

> 50%

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45
Q

status asthmaticus pharmacological treatment

A

B2 agonists including metered dose inhaler, nebulizer (usually given in preop), injection of terbutaline.
IV corticosteroids
1g mag sulfate to relax muscles
oral leukotriene inhibitor

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46
Q

status asthmaticus non pharmacological treatment

A

supplemental O2 if SpO2<90%

-if resistant to ex’s, think airway edema and secretions.

47
Q

why dont you give an asthmatic anticholingerics

A

they need to stay hydrated

48
Q

why dont you give an asthmatic anticholinergics

A

they need to stay hydrated

49
Q

what questions should you ask an asthmatic/what information would you want preoperatively on an asthmatic

A

disease severity and tx effectiveness are big ideas
severity and characteristics of asthma, including use of accessory muscles and active wheezing
previous ICU admissions/intubations
how many ICU admissions/intubations in past year
eosinophil counts (inflammatory process) (CBC, WBC’s)
PFT results at baseline and after bronchodilator therapy to assess responsiveness
presence of co existing diseases

50
Q

for asthmatics, what FVC or FEV1/FVC % is associated with perioperative risk?

A

FVC >70%

FEV1/FVC <65%

51
Q

anesthetic considerations for asthmatics related to induction

A

try to avoid a general, but if you have to put them asleep maybe try an LMA
continue all meds until time of surgery and give stress dose steroids
try deep induction
IV or transtracheal lidocaine induction (and on emergence)
sufficient volatile agent to suppress reactivity of airways
avoid histamine releasing drugs including narcotics (morphine) and paralytics (succ)

52
Q

if an asthmatic starts to have a bronchospasm intraoperatively during a general, do you turn up the gas

A

no, it won’t get to the alveoli. try to get them deep with prop.
administer B2 agonist, consider steroids or mag, administer NMB

53
Q

anesthetic considerations for asthmatics perioperatively

A

light anesthesia can facilitate a bronchospasm
IE ratio adjustment to prevent air trapping (careful with this)
adequate fluid administration
avoid anticholinergic drugs

54
Q

anesthetic considerations for asthmatics and emergence

A

deep extubation as long as you know theyre sufficiently breathing on their own

55
Q

COPD definition

A

non reversible loss of alveolar tissue and progressive airway obstruction. third leading cause of death by 2030

56
Q

risk factors for COPD

A 
cigarette smoking!!!!!!
occupational exposures
pollution
recurrent respiratory infections
low birth weight
a1 antitrypsin deficiency
57
Q

two types of COPD

A

bronchitis, or type B patients. “blue bloaters”

emphysema, or type A patients. “pink puffers”

58
Q

characteristics of emphysema

A

characterized by enlargement of air spaces distal to the terminal bronchiole with destruction of walls.
loss of alveoli and damage to capillaries
small airways are thin, tortuous and atrophied
obstruction of matrix in lower alveolar sacs= shunting and dead space

59
Q

centriacinar emphysema

A

are usually more proximally located on actual alveoli, more common in apex of lung

60
Q

panacinar emphysema

A

either no regional preference, or seen more distally in lobes. depends on who you talk to
located more distally on alveoli
-seen in lower lobes d/t a1 antitrypsin deficiency

61
Q

paraseptal emphysema

A

specific regions of lungs

62
Q

bullae

A

1 big sac versus large alveolar sacs (blown all the way out)

63
Q

acinus

A

describes tissue distal to terminal bronchioles

64
Q

neutrophils and emphysema

A

neutrophils block lysosomal elastane release

65
Q

a1 antitrypsin deficiency and emphysema

A

elastane proliferates, allows for breakdown. congenital in nature.

66
Q

chronic bronchitis characterized by

A

excessive sputum production/expectoration of sputum most days for at least 3 months for 2 successive years

67
Q

hallmark findings of chronic bronchitis

A

hypertrophy of mucus glands of large bronchi
inflammatory changes in small airways that leads to edema
granulation of tissue, smooth muscle increases. increased thickness, decreased airflow
peri bronchial fibrosis
usually patients are in 50’s and older

68
Q

emphysema, PaO2, hypoxemia, diaphragm

A

PaO2 70’s-80’s, not as hypoxemic, inflated lungs flattens diaphragm. all related to distraction of matrix

69
Q

chronic bronchitis, PaO2, hypoxemia, changes related to pulmonary vasculature

A

PaO2 60’s or lower, chronically hypoxemia, pulmonary vasculature changes, pHTN, HF, and edema can ensue

70
Q

definitive dx of COPD requires

A

spirometry

71
Q 
COPD PFT results:
FEV1/FVC ratio:
FEV25-75:
FRC;
TLC:
RV:
A 
FEV1/FVC ratio: decreased. <70% means not reversible with bronchodilators
FEV25-75 decreased
FRC increased
TLC increased
RV increased
72
Q

GOLD spirometric criteria

A

determines severity of COPD, global initiative for chronic obstructive lung disease. a bunch of world health organizations getting together and making up pneumonics to feel like theyre contributing to a cause, whats new.

73
Q

COPD tx

A

designed to relieve sx and slow disease progression
smoking cessation
long term O2 administration, usually 2lpm NC
drug tx (long acting B2 agonists, inhaled corticosteroids, long acting anticholinergic drugs)
vaccinations
diuretics
systemic corticosteroids
theophylline
exercise training programs

74
Q

long term O2 administration usually suggested when:

A

PaO2 <55mmHg
Hct >55%
evidence of for pulmonale

75
Q

drug treatment of COPD includes

A

long acting B2 agonists
inhaled corticosteroids
long acting anticholinergic drugs

76
Q

Lung volume reduction surgery and mechanisms of improvement

A

indicated for severe cases of COPD, take out bad lobe to optimize rest of lung. idea is decreased shunting, decreased dead space, increase in elastic recoil, decrease in amount of hyperinflation, improved diaphragmatic and chest wall movement

77
Q

lung volume reduction surgery anesthetic considerations

A

double lumen tube, avoidance of N2O, avoidance of excessive positive pressure ventilation, LPV, 1 lung ventilation means 3-4ml/kg TV.

78
Q

COPD anesthetic considerations preoperatively

A

preop hx important
smoking history including pk/yr, when they quit
know current meds/continue through DOS
oxygen use/CPAP machine
exercise tolerance/METS score
frequency of exacerbations “how often does this disease debilitate you”
most recent exacerbation and its course
use of non invasive PPV
clinical signs more predictive of pulmonary complications ex)dyspneic, use of accessory muscles, wheezing

79
Q

COPD anesthetic considerations: should they get PFT’s?

A

yes if:
hypoxemia or need for home O2 with no known cause
NaHCO2 >33mEq/L
PaCO2 >50mmHg
hx respiratory failure d/t persistent problem
severe SOB r/t disease
planned pneumonectomy
difficulty assessing pulmonary status through clinical means
differential diagnosis needed
need to determine response to bronchodilators
pHTN

80
Q

COPD anesthetic considerations: postoperative complications risk

A

active clinical s/sx: wheezing, SpO2 <90, no meds taken, has comorbities, METS<3, elderly
age >60
ASA III or IV
current smoker, >60pk/year hx
cardiovascular involvement (RV fx should be assessed by cardiology)
low albumin <3.5g/dL
type of surgery

81
Q

COPD risk reduction strategies

A

cease smoking for at least 6weeks, 8 weeks optimal
optimize nutritional status because malnutrition increases risk of pleural leaks after lung surgery
regional anesthesia because peripheral nerve blockade carries little risk for pulmonary complications

82
Q

what can happen with inter scalene block

A

ipsilateral phrenic nerve palsy, paralyze diaphragm for duration of block.

83
Q

COPD during general anesthesia: volatile agent, N2O, benzodiazepine/opioid considerations

A

volatiles are useful because theyre rapidly eliminated and especially sevoflurane has bronchodilators effects
avoid N2O with any lung pathology where expansion would be detrimental. attenuates HPV, causes VQ mismatch
careful with benzos and opioids, normal dosages can have increased effect on them

84
Q

COPD and mechanical ventilation

A

humidification
avoid hemodynamic hyperinflation of the lungs
Vt 6-8mL/kg
PIP <30cmH2O
FiO2 titrated to maintain SpO2 >90%
so LPV.
(if Pip greater than 30, driving pressure likely >20. not chill)

85
Q

COPD and air trapping and cascade of events

A

aka auto peep, PPV applied without sufficient expiration. increases intrathoracic pressure, decreases venous return, increases pulmonary arterial pressure, results in right heart strain

86
Q

COPD and bronchospasm: what to do

A 
deepen anesthetic
deliver short acting bronchodilator
suction secretions
IV steroids
epi if needed
87
Q

COPD postoperative considerations to optimize this patient

A

lung expansion maneuvers including IS and deep breathing
early ambulation
neuraxial anesthesia

88
Q

expiratory outflow obstructions (5)

A 
bronchiectasis
cystic fibrosis
primary ciliary dyskinesia
bronchiolitis obliterans
tracheal stenosis
89
Q

bronchiectasis definition, result

A

irreversible airway dilation and collapse resulting from inflammation due to chronic infections. pseudomonas is most common organism cultured
resultant airway collapse increases susceptibility for recurrent infections. once established, nearly impossible to eradicate

90
Q

bronchiectasis distinguishing factors (from bronchitis)

A

nasty purulent sputum, hemoptysis (200mL over 24 hour period means significant), pleuritic pain, finger flubbing

91
Q

bronchiectasis dx

A

hx of chronic cough with purulent sputum

92
Q

bronchiectasis dx imaging

A

CT to confirm disease presence and location

93
Q

bronchiectasis s/sx

A

hemoptysis, dyspnea, wheezing, pleuritic chest pain, finger clubbing

94
Q

bronchiectasis anesthetic considerations: preoperative

A

get a detailed patient history including severity, most recent exacerbations, meds taken, make sure to continue DOS
elective procedures should be delayed until patient optimized unless surgery is to correct this

95
Q

bronchiectasis and GETA

A

frequent suctioning, double lumen tube to prevent R to left contamination since this disease is usually pocketed versus diffuse
avoid nasal intubations

96
Q

cystic fibrosis (CF) definition of disease

A

autosomal recessive disorder affect a single gene on chromosome 7. prevents chloride transport and movement of salt and water in and out of cells. also episodic.
(r/t CFTR or cystic fibrosis transmembrane conductance regulator)
-results in abnormally thick sputum production outside of epithelial cells
-this is all cells, not just lung cells. usually anything with secretory ducts.

97
Q

CF provokes damage to

A 
lungs (bronchiectasis, COPD)
sinusitis
pancreas (DM)
liver (cirrhosis)
Gi tract (ileus)
reproductive organs (azoospermia)
98
Q

CF primary cause of morbidity and mortality

A

chronic pulmonary infection

99
Q

CF dx

A

sweat chloride concentration >70mEq/L

-presence of normal sinuses is strong evidence that CF is NOT present

100
Q

CF clinical manifestations

A

chronic purulent sputum production
malabsorption with response to pancreatic enzyme therapy
bronchoalveolar lavage high in neutrophils
COPD common in most adult patients

101
Q

CF tx

A

directed towards allegation of symptoms: airway secretion clearance, correction of organ dysfunction, nutrition, prevention of intestinal obstruction
gene therapy currently being investigated to replace chromosome 7, so this pt needs to be optimized. CPT!
may be taking VitK to help absorb fat soluble vitamins

102
Q

CF anesthetic consideratoins

A

elective procedures should be delayed until patient is optimized including infection control and secretion removal
vitk tx to absorb fat soluble vitamines
volatile agents: increased O2 concentration, relaxation of smooth airway muscles
awake extubation
adequate pain control

103
Q

CF and anticholinergic medicaitons

A

avoid!

104
Q

Primary ciliary dyskinesia

A

congenital impairment of ciliary activity in respiratory tract epithelial cells and sperm cells.

  • patients may have decreased fertility
  • good chance that all organs are reversed..
105
Q

kartageners syndrome

A

triad of chronic sinusitis, bronchiectasis, sinus iversus (seen in half of patients)

106
Q

anesthetic considerations for primary ciliary dyskinesia

A

regional anesthesia preferred
preop focus on pulmonary infection and organ inversion
reverse position of ECG leads r/t dextracardia
left IJ for CVC cannulation versus R
right uterine displacement versus L
avoid nasal pharyngeal airways due to sinusitis risk

107
Q

bronchiolitis obliterans definition

A

disease of small airways and alveoli in children from RSV

108
Q

bronchiolitis obliterans in adults may result from

A

viral PNA
collagen vascular disease (RA)
silo fillers disease (inhalation of nitrogen dioxide)
graft v host disease following transplantation

109
Q

BOOP or bronchiolitis obliterans organizing pneumonia definition and tx

A

shares features of ILD and bronchiolitis obliterans. tx usually ineffective, corticosteroids and bronchodilators will be used.

110
Q

tracheal stenosis reason it occurs

A

following prolonged intubation or over inflation of endotracheal tube cuff.
ischemia of tracheal mucosa results in scarring, may not appear for several weeks after intubation

111
Q

when does tracheal stenosis become symptomatic

A

when diameter decreases to <5mm
dyspnea prominent even at rest
must use accessory muscles in all phases of breathing

112
Q

tracheal stenosis treatment

A

tracheal dilation, temporary measure. balloon or surgical dilators, layering of scarred tissue
tracheobronchial stent can be shorter or long term solution
tracheal resection with anastomosis best treatment

113
Q

tracheal stenosis anesthetic considerations

A

translaryngeal intubation
volatile agents to ensure maximum inspired oxygen concentration
helium, if available, decreases density of gas mixture and improves flow through narrowing

N932 Pathophysiology (4 decks)

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